From June 1, 2014 to July 31, 2015, we identified 81 patients taking pre-injury oral anticoagulants which represented 3.2% of the total trauma registry entries for this time period. Of these patients, 67% were prescribed warfarin and 33% were prescribed DOACs (Dabigatran 12%; Rivaroxaban 12%; Apixaban 9%). The mean age of patients taking DOACs versus warfarin respectively was 77.5 vs. 75.6; 37.0% vs. 55.6% were male and 3.7% vs. 5.5% had concomitant prescription of antiplatelet agents (Table
1). For both groups the most common indication for oral anticoagulation was atrial fibrillation (DOACs 74% vs. warfarin 74%) and the most common mechanism of injury was fall (DOACs 55.5% vs warfarin 76%). Patients on DOACs had similar rates of intracranial hemorrhage (ICH) compared to warfarin (70.0% vs. 66.7%
p = 0.74), Injury Severity Score (ISS) (16.6 vs 20.5
p = 0.06) and Glasgow Come Scale (GCS) (12.9 vs 12.2
p = 0.49). There was a difference in survival to discharge (DOACs: 92%, warfarin: 72%
p = 0.03) (Table
2). Patients on DOACs were less likely to receive prothrombin complex concentrates (PCC) (DOACs: 18.5% vs Warfarin 60%
p = 0.05), received tranexamic acid more frequently (32.1% vs 9.1%
p = .01) and had similar rates of packed red blood cell transfusion (pRBC) in the trauma bay (DOACs: 10.7% vs Warfarin 7.3%
p = 0.6) and total average pRBC transfusion while hospitalized (1.1 units vs 0.82 units
p = 0.72). Patients on DOACs had higher initial hemoglobin values (DOACs: 131 vs. warfarin:120
p = .03) and lower serum creatinine (94.8 vs 129.5
p = 0.17). 66.7% of patients on warfarin were found to have an international normalized ratio’s (INR) greater than 1.5 whereas 33.3% of patients on Anti-Xa inhibitors had INRs greater than 1.5 and 54.5% of patients on Dabigatran had activated partial thromboplastin times (aPTT) greater than 35 s (Table
3).
Table 1
Demographic & clinical characteristics of orally anticoagulated trauma patients
Age | 77.5 | 75.6 |
Male Gender | 55.6% | 37% |
Indication for anticoagulation |
Atrial fibrillation | 76% | 74% |
Thromboembolism | 3.7% | 0 |
Prosthetic heart valves | 1.9% | 0 |
Unknown | 18.5% | 16% |
Clopidogrel use | 5.5% | 3.7% |
Mechanism of Injury |
Motor vehicle collision | 14.8% | 18.5% |
Fall | 76% | 55.5% |
Pedestrian Struck | 3.7% | 14.8% |
Penetrating | 0 | 3.7% |
Other | 5.6% | 7.4% |
Table 2
Injury scores, outcomes & lab values for orally anticoagulated trauma patients
ISS | 20.5 | 16.6 | 0.06 |
GCS | 12.2 | 12.9 | 0.49 |
ICH | 66.7% | 70% | 0.74 |
Survival to Discharge | 72% | 92% | 0.03 |
Hemoglobin | 120 | 131 | 0.03 |
Serum Creatinine | 129.5 | 94.8 | 0.17 |
Table 3
Blood product & coagulation assays for orally anticoagulated trauma patients
Trauma bay pRBC transfusion % | 7.3% | 10.7% | - | - | 0.6 |
Total pRBC transfusion | 0.82 units | 1.1 units | - | - | 0.72 |
TXA administration | 9.1% | 32.1% | - | - | 0.01 |
PCC administration | 60% | 18.5% | - | - | 0.05 |
INR >1.5 | 66.6% | - | - | 33.3% | - |
aPTT >35 s | - | - | 54.5% | - | - |